Biopsy showed a marked lymphocytic infiltrate, which included diffuse, perivascular, and follicular arrangements:
The following stains for organisms were all NEGATIVE: AFB, GMS, HSV1, HSV2, CMV, HHV8, and toxoplasma. An H&E/LFB stain demonstrated that this was a leukoencephalopathic process:
Immunohistochemistry of one of the lymphoid follicles indicated that the lymphoid infiltrate was a reactive, rather a neoplastic process:
Polyoma virus immunohistochemistry for the SV40 (a surrogate marker for JC virus due to cross-reactivity) was found to be positive:
So, the final diagnosis rendered was Progressive Multifocal Leukoencephalopathy (PML) with concomitant Immune Reconstitution Inflammatory Syndrome (IRIS). IRIS is an inflammatory response in HIV-infected individuals upon initiation of HAART therapy. The immune response can be so robust as to cause morbidity, particularly with the brain is involved. Thanks to Dr. Camelo-Piragua for providing the images associated with this interesting case, and I wish her the best of luck in her upcoming move to Ann Arbor where she will take a position on the faculty at the University of Michigan!
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